SweetHART Senior Application

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ADA Visitor
Application
ADA Visitor Transportation on SweetHART
Individuals from outside the HARTransit service area will be served as ADA Visitors on SweetHART if
they are unable to access the CityBus transportation services due to a qualifying disability.
Eligible visitors will be served for a period of 21 days - during any 12 month period.
NAME: ____________________________________________________________________
HOME ADDRESS:____________________________________________________________
APT#: __________ CITY: _______________________________ ZIP CODE: ______________
PHONE #:___________________________________ TDD/TTY: ______________________
BIRTH DATE: ______________________________
MALE
FEMALE
INDICATE IF YOU USE ANY OF THE FOLLOWING:
WHEELCHAIR
WALKER
CANE
SCOOTER
NAME OF TRANSPORTATION PROVIDER THAT CERTIFIED YOUR ADA PARATRANSIT ELIGIBILITY:
_________________________________________________________________________
PHONE #:____________________ CITY: __________________ STATE: ________________
ADDRESS YOU WILL BE VISITING (Within HARTransit service area):
_________________________________________________________________________
APT#: __________ CITY: _______________________________ ZIP CODE: ______________
DATE OF REQUESTED SERVICE: ___________________ THROUGH: ___________________
EMERGENCY CONTACT PERSON: _______________________________________________
PHONE #:__________________________RELATIONSHIP: ___________________________
This application may be faxed, mailed or emailed to info@hartransit.com. Do not send original
documents to our office and make sure copies are legible. By submitting this from, you authorize
HARTransit to contact the certifying district regarding your ADA status. Partially completed
applications will not be accepted.
62 Federal Road, Danbury CT 06810
Tel: (203) 744 4070
Fax: (203) 744 0764
www.HARTransit.com
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